Sbar - Nursing Communication Documentation Form printable pdf download

Patient Label

SBAR – Nursing Communication Documentation Form

Before Calling MD or Provider :

Evaluate resident and complete SBAR form

Check vital signs: TPR B/P O2 sat & glucometer check, urine dip if appropriate

Review chart: recent progress notes, labs, orders

Review relevant Care Path/Acute Change in Status rationale

Relevant Information available when reporting: chart, advance directives, POLST, VS, allergies, medications

S = SITUATION

The symptom/sign/change noted is _______________________________________________________________________

This started __________________________________________________________________________________________

This has gotten (circle one) worse, better, stayed the same since SxS started.

Things that make the condition worse _____________________________________________________________________

Things that make the condition better _____________________________________________________________________

Other things that have occurred with this change ____________________________________________________________

B = BACKGROUND

Primary diagnosis (reason admitted) is _____________________________________________________________________

Pertinent history (recent falls, fever, decreased intake, pain, confusion, SOB, other) _________________________________

Vital Signs: B/P ______ HR ______ RESP ______ TEMP ______ O2 SAT _____

Change in function or mobility: ___________________________________________________________________________

Medication changes or new orders last 2 weeks: _____________________________________________________________

Mental status changes: confusion, agitation, lethargy _________________________________________________________

GI/GU (circle) nausea, vomiting, diarrhea, constipation, distension, urine output, other ______________________________

Pain LEVEL/Location: ___________________________________________________________________________________

Change in Intake/Hydration: _____________________________________________________________________________

Change in skin or wound status: __________________________________________________________________________

Labs: ________________________________________________________________________________________________

Advance Directives/CODE Status (circle): Full CODE, DNR, DNI, DNH, not documented ______________________________

Allergies: ____________________________________ Other Data: _____________________________________________

A = APPEARANCE/ASSESSMENT

There has been an acute change in resident’s condition. It appears to be related to: (circle) cardiac, respiratory, urinary,

dehydration, mental status change, infection, bleeding, circulatory ______________________________________________

____________________________________________________________________________________________________

R = REQUEST

MD or PROVIDER visit or appointment

Lab, X-ray, EKG, other tests ordered: _______________________________________________________________

Pain management: _____________________________________________________________________________

Change in current orders: ________________________________________________________________________

Monitor vital signs/observe and report in: ____________________________________________________ ______

Transfer to Emergency Room: ____________________________________________________________________

Other: ________________________________________________________________________________

MD/Provider SBAR reported to: ____________________________________________ Date/Time: _____________ ______

OUTCOME: ___________________________________________________________________________________________

_____________________________________________________________________________________________

Nursing Signature: ___________________________________________ Date/Time: _______________________________

Sbar - Nursing Communication Documentation Form

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